Pleurisy Pleurisy is inflammation of the parietal pleura that typically results in pleuritic pain and has a variety of possible causes (Boissonnault and Bass 1990). Clinically produces a sharp localized pain, made worse on deep inspiration or coughing, and occasionally twisting or bending movements. A pleural rub may be heard over the site of localized pleuritic pain. Although dry pleurisy occurs, pleural inflammation is generally associated with an exudative pleural effusion (Brims, Davies et al. 2010).
Demographics: In the United States in 2006, 10% of all admissions to emergency departments were a result of diseases of the respiratory system, and chest pain was the most frequent presenting complaint (Brims, Davies et al. 2010). Pulmonary embolism (PE) is the most common potentially life-threatening cause of pleurisy. Studies show that that 5 to 20 percent of patients who present to the emergency department with pleuritic pain are due to PE (Kass, Williams et al. 2007). Other clinically significant conditions that may cause pleuritic pain include; pericarditis, pneumonia, myocardial infarction, and pneumothorax (Kass, Williams et al. 2007).
Clinical Presentation: Most cases the classic presentation of pleuritic pain is pain that increases with forceful breathing movement, such as taking a deep breath, talking, coughing, or sneezing, exacerbates the pain. Patients often relate that the pain is sharp and is made worse with movement. Typically, they will assume a posture that limits motion of the affected area. Pain with respiration may cause patients to complain of shortness of breath or dyspnea (Kass, Williams et al. 2007). The pain referral pattern is to the scapula. The pain referral for PE is to the chest, shoulder, or upper abdominal pain.
Differential Diagnosis: It is important to remember that a through subjective exam is imperative. Pulmonary disease is rarely manifested as a pain syndrome without associated symptoms of disease being present (Boissonnault and Bass 1990). Due to the large variety of conditions that cause pleuretic pain the larger more life threatening disease need to be ruled out prior to a simple diagnosis of pleurisy. These include but are not limited to; PE, pericarditis, pneumonia, myocardial infarction, and pneumothorax (Brims, Davies et al. 2010).
It is important to note that gastrointestinal disorders such as biliary colic and acute appendicitis have similar pain referral patterns.
Physical Examination: Should include percussion and auscultation of the chest, which may reveal signs of dullness, inspiratory crackles, or bronchial sounds to rule out pneumonia and pneumothorax. The presence of constitutional signs and symptoms indicate systemic illness. Evaluation of patients in whom pulmonary embolism is suspected should include an assessment of the probability of pulmonary embolism using a validated clinical decision rule, such the wells rule or test. Patients with PE may present with sudden onset of chest pain, dyspnea, and possibly collapse. (Brims, Davies et al. 2010)
Bottom Line: Refer out A patient that presents to physical therapy with the fore-mentioned presentation should be referred to their primary physician for further testing. A patient with a positive Wells Test should be sent immediately to the Emergency Room. A follow up with the referring physician is important, as the patient may have true musculoskeletal pain in the thoracic region as a result of faulty pain postures, but should not be treated in physical therapy until the systemic illness is resolved.
Please refer to the "Pleurisy" section of the reference list.